Does C7509 require prior authorization?

No, C7509 does not require prior authorization (high confidence). Covered without prior authorization.

`C7509`, Bronchoscopy, rigid or flexible, diagnostic with cell washing(s) when

HCPCS/CPT

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation of pre-procedure CT imaging used for EN planning (CT scans collected and downloaded into the navigation system's software and 3-dimensional reconstruction) and registration parameters (anatomic landmarks) as described in the procedure background.
Procedure notes describing use of the electromagnetic navigation system (e.g., navigation completed, tissue obtained, use of sensor/extended working channel, fluoroscopy/rEBUS use if applicable) to support coding +31627 / C7509-C7511.
When applicable, documentation of attempted standard bronchoscopic access or reasons why standard bronchoscopy and transthoracic biopsy approaches are not appropriate or feasible for the specific lesion.
Pathology/cytology results obtained from the EN-guided biopsy (or documentation of tissue obtained) to support diagnostic intent and medical necessity.

ICD-10 covered diagnoses (when selection criteria are met): R91.1 Solitary pulmonary nodule [peripheral pulmonary nodule]; R91.8 Other nonspecific abnormal finding of lung field [peripheral pulmonary nodules].
CPT/HCPCS codes considered covered when selection criteria are met: +31627 (Bronchoscopy ... with computer-assisted, image-guided navigation); HCPCS C7509, C7510, C7511 (computer-assisted image-guided navigation bronchoscopy codes for diagnostic/cell washing, BAL, and biopsy respectively).
Aetna considers electromagnetic navigation (EN)-guided bronchoscopy medically necessary for individuals with a peripheral pulmonary nodule that requires a pathologic diagnosis and is not accessible by standard bronchoscopy methods or by a transthoracic biopsy approach.
CPT: +31627 — Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with computer-assisted, image-guided navigation (List separately in addition to code for primary procedure[s]) (listed as covered if selection criteria are met)
HCPCS: C7509 — Bronchoscopy, rigid or flexible, diagnostic with cell washing(s) when performed, with computer-assisted image-guided navigation, including fluoroscopic guidance when performed (covered if selection criteria are met)
HCPCS: C7510 — Bronchoscopy, rigid or flexible, with bronchial alveolar lavage(s), with computer-assisted image-guided navigation, including fluoroscopic guidance when performed (covered if selection criteria are met)

AETNA-CPB-0776, Electromagnetic Navigation-Guided Bronchoscopy

REGENCE-SUR179, Electromagnetic Navigation Bronchoscopy

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